World J Oncol

World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access

Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc

Journal website https://www.wjon.org

Original Article

Volume 15, Number 2, April 2024, pages 268-278

Significance of Pretreatment Hemoglobin-Albumin-Lymphocyte-Platelet Index for the Prediction of Suboptimal Surgery in Epithelial Ovarian Cancer

Figure 1. Flow chart of patients within the study. BMI: body mass index; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Gynecology and Obstetrics; HALP: hemoglobin-albumin-lymphocyte-platelet; IDS: interval debulking surgery; NACT: neoadjuvant chemotherapy; NLR: neutrophil-to-lymphocyte ratio; PLR: platelet-to-lymphocyte ratio; PNI: prognostic nutritional index.

Figure 2. Comparison of AUROC between new clinical risk score and the PSC score in discriminating suboptimal surgery cases. AUROC: area under the receiver operating characteristic curve; PSC: predictive cytoreduction.

**Table 1.** Clinical Characteristics
Clinical characteristics	Suboptimal (n = 197)	Optimal (n = 276)	OR	P-value	AUROC (95% CI)
BMI: body mass index; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Gynecology and Obstetrics; HALP: hemoglobin-albumin-lymphocyte-platelet; IDS: interval debulking surgery; NACT: neoadjuvant chemotherapy; NLR: neutrophil-to-lymphocyte ratio; PLR: platelet-to-lymphocyte ratio; PNI: prognostic nutritional index.
Age ≥ 60 years	111 (56.3)	107 (38.8)	2.04	< 0.001	0.59 (0.54 - 0.63)
BMI (kg/m²)
< 25	151 (76.7)	193 (69.9)	-	-	-
25 - 29	41 (20.8)	65 (23.6)	0.81	0.343
≥ 30	5 (2.5)	18 (6.5)	0.36	0.045	0.46 (0.42 - 0.50)
FIGO stage IVA	39 (19.8)	43 (15.6)	1.34	0.233	0.52 (0.49 - 0.56)
High-grade serous	145 (73.6)	214 (77.5)	1.24	0.325	0.52 (0.48 - 0.56)
FIGO grade 3	169 (85.8)	245 (88.8)	1.34	0.334	0.51 (0.48 - 0.55)
ECOG performance status > 2	94 (37.6)	17 (6.2)	9.17	< 0.001	0.66 (0.62 - 0.69)
Comorbidities	76 (38.6)	104 (37.7)	1.04	0.843	0.50 (0.46 - 0.55)
Venous thromboembolism	27 (13.7)	16 (5.8)	2.58	0.004	0.54 (0.51 - 0.57)
Carboplatin plus paclitaxel	184 (93.4)	265 (96.0)	0.59	0.206	0.51 (0.49 - 0.53)
Chemotherapy before IDS > 4 cycles	104 (59.8)	70 (40.2)	3.29	< 0.001	0.64 (0.59 - 0.69)
CA-125 level ≥ 500 U/dL
At diagnosis	154 (78.2)	186 (67.4)	1.73	0.011	0.55 (0.51 - 0.59)
Post-NACT	53 (26.9)	9 (3.3)	10.92	0.001	0.62 (0.59 - 0.65)
Tumor size, cm
0 - 4.9	60 (30.5)	159 (57.6)	-	-	-
5 - 9.9	91 (46.2)	71 (25.7)	3.40	< 0.001
≥ 10	46 (23.3)	46 (16.7)	2.65	< 0.001	0.63 (0.58 - 0.67)
Peritoneal cancer index (1 - 39)
0 - 9	38 (19.3)	151 (54.7)	-	-	-
10 - 20	40 (20.3)	74 (26.8)	2.15	0.004
> 20	119 (60.4)	51 (18.5)	9.27	< 0.001	0.74 (0.70 - 0.78)
Moderate to severe ascites after NACT	90 (45.7)	28 (10.1)	7.45	< 0.001	0.68 (0.64 - 0.72)
Timing of IDS > 42 days	68 (32.5)	103 (37.3)	1.13	0.532	0.51 (0.47 - 0.56)
Laboratory values before the first cycle of NACT
NLR ≥ 3	47 (23.9)	45 (16.3)	1.61	0.042	0.54 (0.50 - 0.57)
PLR ≥ 200	32 (16.2)	16 (5.8)	3.15	< 0.001	0.55 (0.52 - 0.58)
PNI < 45	189 (95.9)	250 (90.6)	2.46	0.031	0.53 (0.50 - 0.55)
HALP index score ≤ 22.6	108 (54.8)	59 (21.4)	4.46	< 0.001	0.70 (0.66 - 0.75)

Table 1. Clinical Characteristics

Clinical characteristics

Suboptimal (n = 197)

Optimal (n = 276)

P-value

AUROC (95% CI)

BMI: body mass index; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Gynecology and Obstetrics; HALP: hemoglobin-albumin-lymphocyte-platelet; IDS: interval debulking surgery; NACT: neoadjuvant chemotherapy; NLR: neutrophil-to-lymphocyte ratio; PLR: platelet-to-lymphocyte ratio; PNI: prognostic nutritional index.

Age ≥ 60 years

111 (56.3)

107 (38.8)

2.04

< 0.001

0.59 (0.54 - 0.63)

BMI (kg/m²)

< 25

151 (76.7)

193 (69.9)

25 - 29

41 (20.8)

65 (23.6)

0.81

0.343

≥ 30

5 (2.5)

18 (6.5)

0.36

0.045

0.46 (0.42 - 0.50)

FIGO stage IVA

39 (19.8)

43 (15.6)

1.34

0.233

0.52 (0.49 - 0.56)

High-grade serous

145 (73.6)

214 (77.5)

1.24

0.325

0.52 (0.48 - 0.56)

FIGO grade 3

169 (85.8)

245 (88.8)

1.34

0.334

0.51 (0.48 - 0.55)

ECOG performance status > 2

94 (37.6)

17 (6.2)

9.17

< 0.001

0.66 (0.62 - 0.69)

Comorbidities

76 (38.6)

104 (37.7)

1.04

0.843

0.50 (0.46 - 0.55)

Venous thromboembolism

27 (13.7)

16 (5.8)

2.58

0.004

0.54 (0.51 - 0.57)

Carboplatin plus paclitaxel

184 (93.4)

265 (96.0)

0.59

0.206

0.51 (0.49 - 0.53)

Chemotherapy before IDS > 4 cycles

104 (59.8)

70 (40.2)

3.29

< 0.001

0.64 (0.59 - 0.69)

CA-125 level ≥ 500 U/dL

At diagnosis

154 (78.2)

186 (67.4)

1.73

0.011

0.55 (0.51 - 0.59)

Post-NACT

53 (26.9)

9 (3.3)

10.92

0.001

0.62 (0.59 - 0.65)

Tumor size, cm

0 - 4.9

60 (30.5)

159 (57.6)

5 - 9.9

91 (46.2)

71 (25.7)

3.40

< 0.001

≥ 10

46 (23.3)

46 (16.7)

2.65

< 0.001

0.63 (0.58 - 0.67)

Peritoneal cancer index (1 - 39)

0 - 9

38 (19.3)

151 (54.7)

10 - 20

40 (20.3)

74 (26.8)

2.15

0.004

> 20

119 (60.4)

51 (18.5)

9.27

< 0.001

0.74 (0.70 - 0.78)

Moderate to severe ascites after NACT

90 (45.7)

28 (10.1)

7.45

< 0.001

0.68 (0.64 - 0.72)

Timing of IDS > 42 days

68 (32.5)

103 (37.3)

1.13

0.532

0.51 (0.47 - 0.56)

Laboratory values before the first cycle of NACT

NLR ≥ 3

47 (23.9)

45 (16.3)

1.61

0.042

0.54 (0.50 - 0.57)

PLR ≥ 200

32 (16.2)

16 (5.8)

3.15

< 0.001

0.55 (0.52 - 0.58)

PNI < 45

189 (95.9)

250 (90.6)

2.46

0.031

0.53 (0.50 - 0.55)

HALP index score ≤ 22.6

108 (54.8)

59 (21.4)

4.46

< 0.001

0.70 (0.66 - 0.75)

**Table 2.** Survival Analysis of Factors Associated With Altered PFS and OS in Patients With AEOC Receiving NACT
Risks	PFS	OS
AEOC: advanced epithelial ovarian cancer; CI: confidence interval; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Gynecology and Obstetrics; HALP: hemoglobin-albumin-lymphocyte-platelet; HR: hazard ratio; NACT: neoadjuvant chemotherapy; NLR: neutrophil-to-lymphocyte ratio; OS: overall survival; PFS: progression-free survival; VTE: venous thromboembolism.
HALP index cutoff score ≤ 22.6	2.92	1.58 - 5.40	0.001	2.66	1.57 - 4.49	< 0.001
Residual tumor ≥ 1 cm	2.02	1.15 - 3.56	0.015	2.48	1.47 - 4.20	0.001
VTE, yes	4.99	2.65 - 9.40	< 0.001	2.08	1.23 - 3.54	0.007
ECOG performance status > 2	6.34	3.39 - 11.87	< 0.001	7.79	4.72 - 12.88	< 0.001
NLR ≥ 3	2.74	1.56 - 4.83	< 0.001	3.36	2.05 - 5.50	< 0.001
FIGO stage IVA	2.37	1.09 - 5.18	0.029	3.34	1.96 - 5.70	< 0.001

Table 2. Survival Analysis of Factors Associated With Altered PFS and OS in Patients With AEOC Receiving NACT

Risks

PFS

95% CI

AEOC: advanced epithelial ovarian cancer; CI: confidence interval; ECOG: Eastern Cooperative Oncology Group; FIGO: International Federation of Gynecology and Obstetrics; HALP: hemoglobin-albumin-lymphocyte-platelet; HR: hazard ratio; NACT: neoadjuvant chemotherapy; NLR: neutrophil-to-lymphocyte ratio; OS: overall survival; PFS: progression-free survival; VTE: venous thromboembolism.

HALP index cutoff score ≤ 22.6

2.92

1.58 - 5.40

0.001

2.66

1.57 - 4.49

< 0.001

Residual tumor ≥ 1 cm

2.02

1.15 - 3.56

0.015

2.48

1.47 - 4.20

0.001

VTE, yes

4.99

2.65 - 9.40

< 0.001

2.08

1.23 - 3.54

0.007

ECOG performance status > 2

6.34

3.39 - 11.87

< 0.001

7.79

4.72 - 12.88

< 0.001

NLR ≥ 3

2.74

1.56 - 4.83

< 0.001

3.36

2.05 - 5.50

< 0.001

FIGO stage IVA

2.37

1.09 - 5.18

0.029

3.34

1.96 - 5.70

< 0.001

**Table 3.** Best Multivariate Clinical Predictors, OR, 95% CI, Logistic Regression Beta Coefficient (β), and Assigned Item Scores
Predictors	OR	95% CI	P-value	β	Score
CI: confidence interval; ECOG: Eastern Cooperative Oncology Group; HALP: hemoglobin-albumin-lymphocyte-platelet; IDS: interval debulking surgery; OR: odds ratio; PCI: peritoneal cancer index.
Age ≥ 60 years	2.86	1.94 - 10.35	0.001	1.05	1
ECOG performance status > 2	2.48	1.25 - 6.27	0.015	0.91	1
Chemotherapy before IDS > 4 cycles	3.27	2.39 - 18.13	< 0.001	1.19	1
CA-125 level before IDS ≥ 500 U/dL	9.11	3.20 - 11.44	< 0.001	2.21	2.5
PCI score > 20	4.59	2.73 - 7.71	< 0.001	1.52	1.5
HALP index score ≤ 22.6	3.08	1.68 - 5.64	< 0.001	1.13	1
Constant	0.25	0.13 - 0.49		-1.37

Table 3. Best Multivariate Clinical Predictors, OR, 95% CI, Logistic Regression Beta Coefficient (β), and Assigned Item Scores

Predictors

95% CI

P-value

Score

CI: confidence interval; ECOG: Eastern Cooperative Oncology Group; HALP: hemoglobin-albumin-lymphocyte-platelet; IDS: interval debulking surgery; OR: odds ratio; PCI: peritoneal cancer index.

Age ≥ 60 years

2.86

1.94 - 10.35

0.001

1.05

ECOG performance status > 2

2.48

1.25 - 6.27

0.015

0.91

Chemotherapy before IDS > 4 cycles

3.27

2.39 - 18.13

< 0.001

1.19

CA-125 level before IDS ≥ 500 U/dL

9.11

3.20 - 11.44

< 0.001

2.21

2.5

PCI score > 20

4.59

2.73 - 7.71

< 0.001

1.52

1.5

HALP index score ≤ 22.6

3.08

1.68 - 5.64

< 0.001

1.13

Constant

0.25

0.13 - 0.49

-1.37

**Table 4.** Distribution of IDS in Patients With AEOC Across Two Different Categories of the Score (Low, Moderate, and High Risk for Suboptimal Debulking)
Risk categories	Score	Suboptimal (n = 197)	Optimal (n = 276)	PPV	95% CI	P-value
AEOC: advanced epithelial ovarian cancer; CI: confidence interval; IDS: interval debulking surgery; PPV: positive predictive value; SE: standard error.
Low	≤ 3	66	22.5	228	77.5	22.4	17.8 - 27.7	< 0.001
Moderate	3.5 - 4.5	83	65.9	43	34.1	65.9	56.9 - 74.0	< 0.001
High	≥ 5	48	90.6	5	9.4	90.6	79.3 - 96.9	< 0.001
Mean ± SE		4	± 1.5	2	± 1			< 0.001

Table 4. Distribution of IDS in Patients With AEOC Across Two Different Categories of the Score (Low, Moderate, and High Risk for Suboptimal Debulking)

Risk categories

Score

Suboptimal (n = 197)

Optimal (n = 276)

PPV

95% CI

P-value

(%)

AEOC: advanced epithelial ovarian cancer; CI: confidence interval; IDS: interval debulking surgery; PPV: positive predictive value; SE: standard error.

Low

≤ 3

22.5

228

77.5

22.4

17.8 - 27.7

< 0.001

Moderate

3.5 - 4.5

65.9

34.1

65.9

56.9 - 74.0

< 0.001

High

≥ 5

90.6

9.4

90.6

79.3 - 96.9

< 0.001

Mean ± SE

± 1.5

± 1

< 0.001